Healthy HSP: Your Personal Error Rate: Checkpoints and Reality Checks

Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland. The views expressed are those of the author and not those of any government agency.

Western cultures tend to look for explanatory causes for trouble outside themselves, sometimes going so far as to blame the victim.¹ Currently, many researchers in the field of error prevention believe that most medication errors occur as a result of multiple, compounding events-or signal collapse of a faulty system-rather than an individual's isolated act. Yet, by focusing on system processes that may lead to medication errors and avoiding the role played by individuals, do we miss an opportunity to improve?

Not to discount the systems approach, because it has its place, but many psychosocial factors also influence a pharmacist's work performance.² Behavior-based programs create better outcomes than technology or any other approach.³ Efforts that address the system and the individual jointly and individually would seem to be prudent. And indeed, that is what researchers have found.

Understanding Work Patterns

First, pharmacists need to understand certain facts about the way we work:

• Each pharmacist's ability to do work is unique.¹ Some pharmacists can fill hundreds of prescriptions every day, whereas others burn out with significantly lighter loads. That is why state regulators do not establish a "safe" number of prescriptions per day, per pharmacist.

• Typically, pharmacists make mistakes most frequently when new to the profession and lacking experience. Once oriented, a long period during which mistakes are rare follows, and then, individuals' error rates tend to increase again, usually as bad habits develop.^4,5

• Defining workload by the number of prescriptions filled, hours worked, or staff scheduled is counterproductive. Work is a process, not a series of discrete events.¹

• All humans "work" on autopilot around 80% of the time.^6,7 This is usually safe. Pharmacists also have an "inner pharmacist" who should kick in when issues out of the ordinary arise.¹ Regardless, in stressful situations, we tend to misapply familiar rules and knowledge.⁸

• Some individuals' propensities and capabilities are hardwired. Much like a sheepdog that herds human guests at a party, they cannot change their abilities and will approach work the same compulsive way, regardless of training.⁵

• Technology can make us lazy. We tend to trust that it will work, and work well, all the time. It does not.⁹

Knowing this, it is crucial that each pharmacist know his or her own tendency to make errors.

In the Workplace

Often, pharmacists cite workload when medication errors occur, recalling that it was very busy. Yet, the workload-error relationship is complex.² Numerous workplace factors create tension and stress. At its best, an adequate tension level speeds information processing, but low or falling mental tension leads to errors. Increasing workloads are not always associated with increasing error rates. On the contrary, error rates generally increase when workload is low,¹ and when workload changes precipitously, at the start of a shift or after a break.^2,4 Should tension accelerate, becoming stressful, pharmacists may begin to ruminate, breaking concentration and increasing the likelihood of errors.¹ Pharmacists should consciously increase vigilance during these times, or reorganize workload when possible to keep it consistent.

The Human Element

Studies have shown that workload alone does not predict outcome; the pharmacist's personal attributes also affect performance.² What human factors increase medication errors?

The precise factors vary, but might include impulsivity or Type A behavior tendencies (impatient, excessively time-conscious, insecure about status, competitive, hostile, and aggressive); poor quality of interpersonal relationships on the job and off; inability to focus on detail and concentrate; few physical comforts in the workplace; depression; substance abuse; and higher stress level.² Individuals who identify factors in themselves that might contribute to errors can take the next step: working on improving (Table).

Creating cues that prompt slowing down and engaging attention is essential.⁴ Finding one's own creative solutions, like always highlighting the suffix of drug names beginning in ceph- or cef- or creating a wall chart listing identifying markings on generic tablets, makes improvement more likely, reducing potential for error.⁸

Keep in mind that data entry errors represent about 25% of all medication errors.¹⁰ As pharmacists age, declining vision or hearing can be insidious. One study found that 3% of pharmacists have unidentified hearing or vision deficits.⁸ Several steps can help: keeping prescriptions at eye level when entering data into the computer,¹⁰ using supplemental lighting or a magnifying glass,¹ and using the "show and tell" method of counseling when patients pick up prescriptions.¹⁰ At least 30% of errors can be detected during counseling.¹

If lack of drug knowledge or bad habits acquired midcareer is the problem, training is the answer.^4,5 Although on-the-job training is often available, it may not meet a specific need, or training may be underfunded and unable to address a targeted need.⁸ In that case, pharmacists have a professional responsibility to seek training on their own. When selecting training to meet continuing education requirements, consciously looking for offerings that address 2 areas is prudent: knowledge gaps and exceptional events that are likely to occur.⁴

If workplace distractions are the problem, very small changes can make large differences by decreasing turbulence. Learning to work with instead of against or parallel to coworkers and supervisors can improve the environment.^8,11 The key: telling your supervisor how you best hear constructive criticism and delivering constructive criticism to others in a positive way.

Finally, be aware when you are fatigued or not at your peak, and enlist coworkers' help by asking them to watch your work.^4,8 Every pharmacy should empower employees to pause or even stop the work process entirely if they believe that an error is in process.⁴

Despite our best intentions, errors sometimes escape scrutiny. Randomly checking completed work that has apparently passed verification sometimes identifies problem areas. But, some errors are just that--unfortunate events that could not be anticipated and occurred due to a confluence of factors.⁸

References

1. Grasha AF. Misconceptions about pharmacy workload. Can Pharmaceut J. 2001;134(4):26-35.

2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34.

3. Guastello SJ. Do we really know how well our occupational accident prevention programs work? Saf Sci. 1993;16:445-446.

4. Barry R, Murcko AC, Brubaker CE. The Six Sigma Book for Healthcare. Ann Arbor, MI: Chicago Health Administration Press; 2002:19-43

5. Bogner MS. Misadventures in Healthcare. Mahwah, NJ: Lawrence Erlbaum Associates; 2004:1-186

6. Ashcraft MH. Human Memory and Cognition. 2nd ed. New York: Harper Collins; 1994.

7. Anderson JR. Learning and Memory: An Integrated Approach. New York: John Wiley&Sons; 1995.

8. Grasha AF. Into the abyss: seven principles for identifying the causes of and preventing human error in complex systems. Am J Health Syst Pharm. 2000;57(6):554-564.

9. Casey S. Set Phasers on Stun: And Other True Tales of Design, Technology and Human Error. Santa Barbara, CA: Aegean; 1998.

10. Schell KL, Grasha AF. State anxiety, performance accuracy, and work pace in a simulated pharmacy dispensing task. Percept Mot Skills. 2000;90(2):547-561.

11. Grasha AF. Tools for the reflective practitioner: using self-monitoring, personal feedback and goal setting to reduce errors. In: California State Board of Pharmacy. Health Notes: Quality Assurance. 2002:19-24.